Surgical chylothorax in neonates:management and outcomes

Background Postoperative chylothorax occurs due to trauma to lymphatic vessels and can occur after any thoracic proce-dure.This study reviewed recent literature to evaluate the management and outcomes of surgical chylothorax in neonates.Methods PubMed database was searched for articles in English,Portuguese and Spanish from 2000 to 2016.Data were collected for surgery,chylothorax management,complications,mortality and length of hospital stay(LOS).Results Twenty studies offered 107 neonates:congenital diaphragmatic hernia(CDH)(n=76,71%),cardiac malforma-tions(n=25,23.4%),esophageal atresia(n=5,4.7%)and CDH+extralobar sequestration(n=1,0.9%).Medium-chain tri-glycerides(MCT)was the initial treatment in 52 neonates(48.6%),prednisolone+MCT in one(0.9%),total parenteral nutri-tion in 51 patients(47.7%),and three patients(2.8%)did not require any treatment.Octreotide and somatostatin were used as second or third line treatment in 25 neonates(23.4%),and 15 neonates(14%)underwent 17 surgeries,including thoracic duct ligation(TDL)(n=9);pleurodesis(n=3)(2 patients required TDL);TDL+pleurodesis(n=2),and TDL+placement of hemostat(n=1).Complications due to the chylothorax were reported in 27 neonates(25.2%):hypoalbuminemia+hypona-tremia(n=18),hypoalbuminemia(n=4),hypoalbuminemia with cutaneous flushing as colateral effect of somatostatin(n=1),loose stool after somatostatin use(n=1),pneumonia(n=1),congestive heart failure+hypernatremia(n=1),and hyponatremia(n=1).There were 21 deaths(19.6%)and median LOS was 53.4 days(30-93.1 days).Conclusions Conservative management is appropriate as initial treatment for neonatal postsurgical chylothorax.Octreotide and somatostatin are safe in neonates and surgical approach should be considered in prolonged leaks.

Complications in children with percutaneous endoscopic gastrostomy (PEG) placement

Introduction The aim of this study was to analyze the complication rates and mortality in association with different operative techniques of percutaneous endoscopic gastrostomy (PEG),age,underlying diseases and other risk factors.Moreover,analysis of the indications of PEG insertion and the underlying comorbidities was also performed.Methods This study performs a literature analysis of PEG-related complications in children.Literature was searched on PubMed(R) (1994-2017) using terms 'percutaneous endoscopic gastrostomy','complications','mortality' and 'children'.Results Eighteen articles with 4631 patients were analyzed.The mean age was 3 years (0-26 years).Operative techniques were:pull technique in 3507 (75.7%),1 stage PEG insertion in 449 (9.7%),introducer technique in 435 (9.4%),image-guided technique in 195 (4.2%) and laparoscopic-assisted PEG in 45 (1.6%).Most frequent indications for PEG insertion were dysphagia (n =859,32.6%),failure to thrive (n =723,27.5%) and feeding difficulties (n =459,17.4%).Minor complications developed in n 1518 patients (33%),including granulation (n =478,10.3%),local infection (n =384,8.3%) and leakage (n =279,6%).In 464 (10%) patients,major complications occurred;the most common were systemic infection (n =163,3.5%)and cellulitis (n =47,1%).Severe complication like perforation occurred in less than 0.3%.Patients with lethal outcomes (n =7,0.15%) had severe comorbidities;and the cause of mortality was sepsis in all cases.Prematurity or young age did not affect complication rate.Patients with ventriculoperitoneal (VP) shunt had higher risk of major complications.In high-risk patients,laparoscopic-assisted PEG insertion had less major and severe complication than traditional pull technique.Conclusions PEG is a safe operative technique;although minor complications are relatively common and occur in up to 1/3 of patients,there is a fairly low rate of severe complications.Two-thirds of PEG patients have at least one comorbidity.Patients with VP shunt have higher risk of major complications.In high-risk patients,laparoscopic-assisted PEG is recommended.

Asynchronus bilateral ovarian torsions in girls-systematic review

Background:Bilateral ovarian torsions with complete loss of ovaries is devastating.This study analyzed the literature on bilateral ovarian torsions in girls to evaluate surgical options and outcomes.Methods:Literature was searched on Pubmed(R)(1987-2014) using terms 'bilateral','adnexal','ovary','torsion' and 'children'.Data were collected on age,surgical preference,pathology and outcomes.Results:Thirteen articles were identified,and 9 met the inclusion criteria (5 case reports,4 original articles);and analyzed 17 girls (mean age:8.75 years,range:1-16).Bilateral oophorectomies (n=4),ipsilateral oophorectomy of severely affected ovary and contralateral oophoropexy (n=10),and detorsion of bilateral ovaries and bilateral oophoropexy (n=3) were performed.One torsion recurrence occurred after two oophoropexies.Laparoscopy and open surgery was done in 2 and 15 girls,respectively.Considering etiology,there were simple tubo-ovarian torsions (n=8),polycystic ovary (n=1),polycystic ovary associated with Down syndrome (n=1) and corpus luteum cyst (n=1).No tumors were reported.Serial ultrasound follow-ups of ipsilateral oophorectomy and contralateral oophoropexy (n=5) confirmed follicular function (n=4) and viability and position of the ovary (n=l).Conclusions:Though extremely rare,school age girls present bilateral ovarian torsion,Ipsilateral oophorectomy and contralateral detorsion with oophoropexy has been the preferred approach.